CDI Glossary Flashcards
ACDIS
Association of Clinical Documentation Improvement Specialist. The national professional organization for CDI specialist. Provides networking, resources, and has developed a s certification, the Certified Clinical Documentation Specialist (CCDS)
Admitting Diagnosis
An initial impression/diagnosis made by a qualified provider/physician
AHIMA
American Health Information Management Association. The national professional organization that credentials Registered Health Information Administrators (RHIAs), Registered Health Information Technicians (RHITs), and Certified Coding Specialist (CCSs); one of the four Cooperating Parties
AHA
Americal Hospitial Association. The organization that houses and staffs the Central Office on ICD-9-CM and publishes the Coding Clinic for ICD-9-CM; one of the four Cooperating Agencies
CMI
Case Mix Index. The calculation reflecting the cost of treating all Medicare inpatient cases in a particular facility relative to the national average cost of treating all Medicare inpatient cases in the U.S.
CMS
Centers for Medicare and Medicaid Services. The branch of the Department of Health and Human Services responsible for administering the Medicare program and maintaining the procedure portion of the ICD-9-CM; one of the four Cooperating Parties
CFR
Code of Federal Regulation
Coding Clinic for ICD-9-CM
The publication of the AHA Central Office on ICD-9-CM that provides information and official coding guidelines as unanimously approved by the four Cooperating Parties
CC
Comorbidity
A condition that coexist with the principle diagnosis AT THE TIME OF admission that can with specific principle diagnosis, affect the treatment received, the length of stay, or the cost of care and, consequently, the Medicare payment. Must be evaluated, treated, assessed, or monitored.
Complication
A condition arising AFTER the time of admission that can, with specific principle diagnosis, affect the treatment received, the length of stay, or the cost of care and, consequently, the Medicare payment.
COP
Conditions of Participation. Requirements or criteria that a hospital must meet in order to qualify to receive Medicare and Medicaid payments. The conditions are updated and verified each year. (See Social Security and Medicare Law in Title 42 of the CFR.
Cooperating Parties
A partnership, consisting of representatives from the American Hospital Association, the National Center for Health Statistics, the Health Care Financing Administration and the American Health Information Management Association, that is recognized as the official authority on ICD coding in the U.S.
DHHS
Department of Health and Human Services. The government agency responsible for administering all federally-funded health programs.
DRG
Diagnosis Related Group. Under the Medicare Inpatient Prospective Payment System (IPPS), the groupings of patients by clinical similarity and consumption of hospital resources
Diagnostic Procedure
A procedure performed to help establish diagnosis
DRG Grouper
A software program used by Medicare and other third party payers to assign each hospital inpatient discharge to a DRG on the basis of information (principal and secondary diagnosis, procedures, age, gender and discharge status) abstracted from the patient’s medical record.
Fiscal Year
The operating budget year begins October 1st for the Federal government
Hospital Blended Rate
A regulated rate calculated for a hospital to reflect inflation, technical adjustments, budgetary constraints, geographic location, local wage variations, and other factors that affect the hospital’s operating budget; when multiplied by a DRGs relative weight, the result is the Medicare payment for a case in that DRG for that particular hospital.
ICD-9-CM Coordination and Maintenance Committee
The committee established in 1985 to provide a public forum for discussing possible updates and
revisions of the ICD-X-CM; it is co-chaired by the Health Care Financing Administration and the Center for Health Statistics; petitions for creation or revision of ICD codes are presented to the committee for the purpose of being able to track diagnoses or procedures by specific codes and accumulate more meaningful data
MCC
Major Complication/Co-morbidity. Diagnosis codes that reflect the highest level of severity
MDCs
Major Diagnostic Categories. Under the Medicare Inpatient Prospective Payment System, divides all possible principal diagnoses ICD codes into 25 mutually-exclusive categories to which DRGs are assigned, most of which are based on a particular body system
MCE
Medicare Code Editor. A grouper screening editor that detects and flags coding errors that appear on billing claims, including invalid diagnosis and procedure codes, invalid fourth or fifth digit code digits, E codes as principle diagnosis, age and gender conflicts, manifestations used as principal diagnoses, non-specific principal diagnoses, questionable admissions, unacceptable principal diagnoses, non-specific operating room procedures, non-covered procedures, open biopsy verification, Medicare as secondary payer alert, bilateral procedures, and invalid discharge status.
NCHS
National Center for Health Statistics. One of the four Cooperating Parties and the co-chair for the ICD-X-CM Coordination and Maintenance Committee; it has responsibility for maintaining the DIAGNOSIS portion of the ICD coding system
Penalty Statement
An acknowledgement signed and dated by physicians who treat DRG payment based patients- usually when the physicians are granted hospital privileges- stating they have received the Notice to Physicians delineating the penalties for misrepresenting, falsifying, or concealing essential information required for payment of federal funds; the statement must be on file in the hospital before bills are submitted to Medicare or else the claim for payment may be denied
POA
Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission.
Present on Admission. Defined as present at the time the order for inpatient admission occurs.
Reporting Definition YES
Chronic conditions diagnosed after discharge
Preset at the time of INPATIENT admission. #Diagnosis prior to admission or clearly present but not diagnosed until after admission occurred (documented as suspected, possible, rule out, differential diagnosis, or constitute an underlying cause of a symptom that is present at the time of admission)
Reporting Definition NO
Assign “N” if any part of the combination code was not present on admission (e.g., obstructive bronchitis with acute exacerbation and the exacerbation WAS NOT present on admission; gastric ulcer that does not start bleeding until AFTER admission; asthma patient develops status asthmaticus after admission
Not present at the time of INPATIENT admission.
Reporting Definition Unknown
Documentation is insufficient to determine if condition is present on admission
Reporting Definition “W”
Provider is unable to clinically determine whether condition was present on admission or not
Principal Diagnosis
As defined by the Uniform Hospital Discharge Data Set (UHDDS) “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
Principal Procedure
The procedure performed for definitive, therapeutic treatment rather than for diagnostic or exploratory purposes, or one necessary to treat a complication; the procedure MOST related to the principal diagnosis
IPPS
Inpatient Prospective Payment System. The payment system for Medicare acute care inpatient services based on predetermined specific rates for each hospital discharge
QIO
Quality Improvement Organization. Formerly, called the Peer Review Organization (PRO), reviews the reasonableness and appropriateness of admissions and discharges, and other aspects of the inpatient care furnished by a hospital.
RAC
Recovery Act Contract. Medicare Integrity Program that identifies underpayments and overpayments and recouping overpayments under the Medicare program for services for which payment is made under part A or B of title XVIII of the Social Security Act.
RW
Relative Weight. The number weight assigned to a DRG to indicate the severeity andrelative resource consumption associated with the DRG.
Secondary Diagnoses
All medical conditions, other than the principal diagnosis, associated with the current hospital episode and documented by the physician which are either clinically evaluated, diagnostically treated; therapeutically treated or cause an increase in length of stay or additional nursing care.
Therapeutic Procedure
A procedure performed for definitive purposes rather than for diagnostic or exploratory reasons.
Uniform Bill - 04
A billing form, created in 1982 and revised in 1992 containing the patient’s charges that is submitted to Medicare and other third-party payers for payment; it provides for the listing of up to ten diagnoses and six procedure codes assigned to a particular case
UHDDS
Uniform Hospital Discharge Data Set. Created by the National Committee on Vital and Health Statistics of the U.S. Public Health Service, the UHDDS contains 14 items recommended as basic data for hospital discharge statistics: personal identification, date of birth, sex, race, ethnicity, residence, hospital identification, admission and discharge dates, physician identification (attending and surgeon) diagnoses, procedures and dates performed, disposition/discharge status and the expected payer for most of the bill
HAC
Hospital Acquired Conditions
- High cost or high volume
- Result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnoses
- Could reasonably have been prevented through application of evidence-based guidelines
Blended Rate
A “set” dollar amount assigned to each facility based on the blending of various factors, including whether a hospital has a disproportionate share of treating the community’s indigent population, capital cost, and if it is an urban/rural facility, a sole community provider, or teaching/non-teaching facility
ICD-9-CM
International Classification of Diseases, 9th Revision, Clinical Modification
Developed by the World Health Organization to arrange diseases and procedures into specific groups.
Designed to classify morbidity and mortality, indexing of diseases and storage of data.
